Module 1 Flashcards
Florence Nightingale
Founder of Nursing
Noticed relationship between environment and health
Dorothea Dix
Established Nurse Corps of the United States Army
Clara Barton
Organized the American Red Cross
Peplau’s theory
Interpersonal relations with patients. Nurse must become their counselor and caretaker and tailor to individual needs of the patient
Henderson’s theory
Holistic care, 14 major needs
Role of nurse is to assist in meeting the patients basic needs when they cannot do so independently
Roger’s theory
Patients are whole, and constantly interacting with their environment.
Role of nurse is to facilitate change in the patients energy field, and maintain balance.
Orem’s theory
Surrounding self care deficit.
Nurses are use assessment, diagnosis, planning, implementation, and evaluation to find patient’s self care deficit and develop and implement care.
Neuman’s theory
Health Care System Model.
Focuses on human stressors and emphasizes need to cope with them.
Roy’s theory
Adaptation Model.
Focuses on how patients adapt to their environment, so the role of nurses is to assist in adapting to their new environment.
Maslow’s hierarchy
From bottom to top:
Physiological needs - food, water, breathing, shelter, clothing sleep
Safety & security - health, employment, family, property
Love and belonging - friends, family, intimacy, connection
Self esteem - confidence, respect, achievement
Self actualization - morality, creativity acceptance
CABD
Chest compression
Airway
Breathing
Defibrillation
QSEN
Quality and Safety Education for Nurses
Purpose: prepare nurses with competencies necessary to improve quality and safety of Healthcare
Patient centered care
Patient is in control
Nurses provide care based on patient’s preference, values, and needs
Health assessment
Establish a database
Identify patient risk factors and strengths/limitations
Compare assessment with baseline norms
Components: health history and physical assessment
Health history
First step in establishing trust.
Medication
Past surgery
Family history
Personal/social history
Review of systems
Physical exam
Head to toe - organized, comprehensive
Body systems - Focused on specific systems
Functional health patterns - focus on effects of health or illness on patient’s QOL
Includes holistic care
Assessment examination order
NON-ABDOMINAL: Inspection, palpation, percussion, auscultation
ABDOMINAL: inspection, auscultation, percussion, palpation
Bell vs Diaphragm
Bell - low pitched sounds (vascular sounds, heart murmur, bruit)
Diaphragm - high pitched sounds (B/P, heart sounds, lung sounds, abdominal)
Primary vs secondary sources
Primary: from the patient themselves
Secondary: anyone else
Subjective vs Objective data
Subjective: Verbal, from the patient
Objective: signs detected by the nurse during examination
Sounds of percussion
Tympany - loud and drum like - air filled structure like intestine
Resonance - low pitched - air filled hollow organ
Hyperresonance - loud and booming - air around organ
Dullness - thud and muffled - fluid or solid organs
Flatness - soft and short. - solid tissue and bone
Space and territoriality zones
Intimate zone - 0 to 18 in
Personal zone - 18 in to 4 ft
Social zone - 4 to 12 ft
Public zone - 12ft and beyond
Always explain to patient what you are doing first
Phases of nurse-client relationship
Orientation/initiating - establishing trust/rapport
Working - The patient is an active participant
Termination - closure of the relationship
Hand-off communication (SBAR)
Situation
Background
Assessment
Recommendation
Communication facilitators
Open-ended questions
-Allows patient to talk. Start with what, how, tell me more
Validating
-What the nurse believes the patient said
Clarifying
-Offers back to the speaker the essential meaning
Reflective
-Focuses on patient’s feelings
Silence
-Allows client time to think
General leads
-Encourages client to talk and indicates interest
Direct question
-Obtains more info about topic
Providing information
-Informs the patient of facts needed to understand situation
Sharing observations
-Calling patient’s attention to what is observed
Offering self
-Willingness to spend time with patient
responses to avoid in therapeutic communication
False reassurance
* Closed-ended questions
* Giving advice
* Sharing personal opinions
* Changing the subject
* Using personal terms of endearment
* Asking for explanations: avoid questions
that begin with “WHY”
Average temperature when taken orally
98.6F and 37C
4 ways of heat loss
Radiation - transfer of heat into environment (walking into a refrigerator)
Conduction - Transfer of heat from body to another surface
Convection - dispersion of heat, like a fan on the body
Evaporation
Why shouldn’t we give Asprin to someone under 16?
May cause Reye’s syndrome
Hyperthermia temp
~102.2F / 39C
Hypothermia temp
Less than 95F / 35C
Movement of ear for tympanic thermometers
Adults: back, up, out
Children: back, down
Pulse strengths
0 - absent
+1 - diminished, weak
+2 - normal
+3 - bounding
Respiration rates
Norm: 12-20
Tachypnea - greater than 24
Bradypnea less than 10
Normal pulse oximetry
95-100%
Pain assessment: OLDCART
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment
What is the assessment tool for pain?
Wong-Baker Tool
What is a nosocomial infections
Hospital acquired
When do you wash hands
When hands are visibly soiled
Working with high risk clients
Working with body fluids or spore forming organisms
When should vitals be taken
- On admission
- As part as the physical assessment
- Routine monitoring
- With any change in the patient’s health
status - Before & after surgery or invasive
procedures - In ongoing care to detect improvement in
patient condition - Before discharge or transfer to another
unit
What is erythema
Redness of skin, common in pressure injuries
Lowest and highest Braden score?
6 - 23
Petechiae
Pin point red or purple spots
May indicate blood clotting disorders, drug reactions or liver disease
Edemas
+1 - 2mm immediate rebound
+2 - 4mm couple seconds to rebound
+3 - 6mm 10-20 seconds to rebound
+4 - 8mm 20+ seconds to rebound
ABCDE for melanoma
Asymmetry
Border irregularity
Color varies from blue to black
Diameter greater than 6mm
Evolving over time
Hirsutism
Increased hair growth on upper lip, chin, cheeks. Check for this in women
Clubbing of fingers caused by?
chronic pulmonary disorders
